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October 2003 – Referred Pain to the Opposing Arch
This female patient was referred to me for treatment of a maxillary molar tooth. The referral was unsure of which tooth was causing the problem but he was convinced that the problem was originating from the maxilla because that was where the patient was pointing. No pulp tests were performed at the time and the patient was sent to my office with very little history other than that she had a severe toothache.
The maxillary periapical films showed multisurface amalgam restorations in both molars. They were fairly deep but the margins were good and the fillings were not too recent. ( 80% of acute tooth related problems I see have a history of recent ( within the last 12 months) treatment of some kind.
Pulp tests were performed on all the entire maxillary right posterior/anterior quadrant. No abnormal findings were noted. Percussion, palpation and periodontal findings were within normal limits. Transillumination was negative for cracked tooth in the 2nd premolar.
I decide to review the bite wings again. ( Bite wing radiographs should be a MANDATORY part of your examination - regardless of whether the patient is convinced the discomfort is in one particular arch.) The mandibular first molar had a very shallow amalgam but the 2nd molar showed particularly high Mesial pulp horns.
A Periapical radiograph of the mandibular molar area confirmed my suspicions. Pulp tests of the second molar showed no response to cold but delayed and severe response to heat. The tooth was slightly percussive sensitive as well.
A mandibular block was administered and the patient's symptoms disappeared. A pulpectomy procedure was performed at which time I found the typical "watery - semi necrotic" pulp that is typical in end stage pulpitis. The tooth was temporized with CaOH dressing and closed. Unfortunately, the patient elected for extraction rather than endodontic treatment and restoration.
The pain referral pattern for mandibular molars ( when referred to other teeth) is typically anteriorly, toward the bicuspid area (black arrow below) . We also have to remember that pain can be referred to the opposing arch as well (Red arrow). Patients can be quite insistent about the source of their symptoms but at the same time be completely wrong.
Proper Diagnosis demands that we maintain an attitude of "Methodical Skepticism". While the patient's symptoms may seem obvious, we must always remember that pain referral is not uncommon and that before we consider accessing a tooth to perform endodontic treatment, we must have corroborating evidence that justifies the treatment.